Antibacterial Resistance Patterns Among Common Infections in a Tertiary Care Hospital in Saudi Arabia

Background The rapid emergence of antibiotic-resistant bacteria threatens the control of infectious diseases by reducing treatment effectiveness, prolonging illness duration, and increasing healthcare costs. This study aimed to identify the common rate of bacterial resistance against antibacterial agents in tertiary healthcare providers in Saudi Arabia. Methodology This retrospective cross-sectional observational study was conducted from May 2016 to December 2019 on 1,151 urinary tract infection (UTI) and respiratory tract infection (RTI) positive cultures collected from participants aged 15 years or older who received antibiotic treatment. The obtained variables included age, gender, diagnosis, antibiotic type, specimen source, culture results, and sensitivity test results. Results The most common bacteria in UTI were Escherichia coli (46.7%), followed by Klebsiella pneumoniae (30.5%). Moreover, E. coli was most resistant to ampicillin (56.4%), followed by ceftriaxone (33.8%). Among the respiratory cultures, the most frequently isolated pathogen was Pseudomonas aeruginosa (28.5%), followed by K. pneumoniae (17.6%). The 162 respiratory P. aeruginosa isolates were most resistant to piperacillin/tazobactam (51.9%), followed by ciprofloxacin (25%) and ampicillin (10.6%). Conclusion High levels of antibiotic resistance were observed in both Gram-negative and Gram-positive bacteria. This indicates a need for better implementation of antibacterial stewardship and increased awareness of appropriate antibiotic use to limit the rapid spread of antibacterial resistance.


Introduction
The introduction of antibiotics to the medical field was one of the greatest discoveries in the history of medicine. When penicillin was introduced in the 1940s by Alexander Fleming, a new era of therapeutic medicine was established [1]. The outcomes of bacterial infections saw a great turnaround as fatal and severe infections became easily treatable. However, the efficiency of antibiotics has decreased as many available antibiotics are no longer effective along with the emergence of antibiotic-resistant (ABR) strains. Importantly, antibiotic resistance discovery is related to resistance detection in clinical samples; however, the resistance might be discovered earlier according to the observation from laboratory samples.
Globally, it is estimated that ABR infections are responsible for approximately 700,000 deaths per year [2,3]. If no preventative actions are taken, it is predicted that infections caused by ABR bacteria will have a mortality rate exceeding that of cancer and become the most common cause of death by the end of 2050 [2,3]. According to the Centers for Disease Control and Prevention (CDC), approximately 35,900 deaths out of 2,868,700 ABR cases are expected to be reported annually in the United States [2]. In 2012, Aly et al. investigated antimicrobial resistance in 37,295 bacterial isolates collected from different hospitals in the Gulf region. Within this sample, the most prevalent microorganism was Escherichia coli, followed by Klebsiella pneumoniae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, Clostridium difficile, and Enterococcus [4]. In addition, a study conducted by the Saudi national surveillance on Gram-positive cocci revealed that 32% of S. aureus belonged to MRSA, 33% of S. pneumoniae were resistant to penicillin G, and 26% of S. pneumoniae were resistant to erythromycin [3]. In the western region of Saudi Arabia, Alam et al. reported bacterial resistance to trimethoprim/sulfamethoxazole (48.6%), ampicillin (49.3%), piperacillin (59.3%), and methicillin (50.3%) [5].
Bacteria have the unique ability to lower or eliminate the antimicrobial efficacy of drugs and chemical agents [6]. This may occur through natural resistance (e.g., β-lactamase production) or acquired resistance [7,8]. Acquired bacterial resistance may occur through four mechanisms. One of these mechanisms is the production of enzymes that modify or inhibit antibiotic action [7][8][9]. Another mechanism is through changes in the permeability of bacterial cell walls [7]. Bacteria can also acquire resistance through disruptions in protein synthesis [7], alterations in metabolic pathways, or genetic mutations [8]. Finally, bacteria can acquire resistance from the transferred copy of the plasmid (R-plasmid genes) of a previously resistant bacteria [7][8][9].
The development of antibiotic resistance appears to be inevitable [10]. However, the overuse and misuse of antibiotics are accelerating this process [11]. The misuse of antibiotics is a complex problem driven by several factors related to patients, healthcare providers, and institutional healthcare regulations [12]. Public knowledge, awareness, and attitudes regarding antibiotic use are strong determinants of antibiotic misuse [13]. In a systematic review conducted by Alhomoud et al. in 2017 and demonstrated the use of antibiotics in the Middle East, the overall prevalence of participants who used antibiotics as self-prescription ranged from 19% to 82% [14]. The highest prevalence of self-prescription antibiotics was reported in Yemen and Oman followed by Saudi Arabia [14]. Access to antibiotics without a prescription and gaps in knowledge and safe practices regarding antibiotics' use (e.g., keeping leftover antibiotics from an uncompleted course for future use and sharing antibiotics with others) were among the reported reasons for self-medication with antibiotics [14]. Furthermore, prescribers' knowledge and attitudes regarding antibiotic use and resistance have been reported to determine the quality of antibiotic prescriptions [15]. One core problem underlying improper antibiotic prescription is the lack of sufficient diagnostic tests to rapidly identify pathogens and their antibiotic susceptibility profiles [16]. Another proven risk factor for antibiotic resistance is travel, specifically during the Hajj season, when the acquisition and transmission of infectious diseases (including those caused by ABR bacteria) are common occurrences [17].
The topic of antibiotic resistance has been approached from many perspectives for a wide variety of clinical and social practices and implications. However, the present research specifically aimed to assess the prevalence of ABR infections in Ministry of National Guard-Health Affairs (MNGHA), Jeddah, Saudi Arabia. In a study conducted in the western region of Saudi Arabia, pneumonia was the most prevalent infectious disease reported in patients aged 26-45 years [18]. Additionally, pneumonia and urinary tract infections (UTIs) were the most prevalent forms of infectious diseases among female patients [18]. In the central region of Saudi Arabia, respiratory tract infections (RTIs) and UTIs have been found to be the most frequent complaints encountered in emergency departments [19]. The availability of updated epidemiological data from a given region or community is important not only for the optimization of empirical therapies but also for the implementation of an effective antimicrobial stewardship program in hospitals [20].

Selection criteria
An observational cross-sectional quantitative study (with non-probability convenience sampling) was conducted in the MNGHA, Jeddah, Saudi Arabia. For this study, patients were selected according to the following criteria: male and female Saudi inpatients and outpatients aged 15 years or older who had received antibiotic treatments prior to the initiation of the study for UTIs and/or RTIs. This sample excluded the oncology department, patients infected with tuberculosis (TB), and patients infected with human immunodeficiency virus (HIV).

Data analysis
Parametric and non-parametric approaches were used to describe the numerical data (age and date of diagnosis). Percentages were used to describe the categorical variables (gender, hospital setting, diagnosis, antibiotic type, specimen source, type of organism, and sensitivity test results). Chi-square or Fisher exact test was used to compare categorical data, while t-test and ANOVA were used to make comparisons between categorical and numerical variables. A p-value of less than 0.05 was statistically significant. All data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (Released 2011; IBM Corp., Armonk, New York, United States).

Ethical approval
The study was carried out in line with the Helsinki protocol and ethical approval from the Institutional Review Board of King Abdullah International Medical Research Centre, Jeddah, Saudi Arabia, was duly acquired prior to conducting this study (approval number: SP20/050/J, dated April 22, 2020). No names and Identities (IDs) were collected from the participants, and the data were stored within 64-bit encrypted software on the work computer of the primary investigator that was not liable to be breached by nonauthorized persons.

Discussion
The growing incidence of antibiotic resistance is a substantial concern globally and is considered the main hurdle to the effectiveness of treating bacterial infection/ Table 10 shows the list of antibiotic resistance over time. Importantly, the resistance discovery dates in Table 10 are according to the observations during clinical practice, however, the resistance might have appeared earlier based on the findings from laboratorybased experiments.  The growing prevalence of ABR bacteria may affect the capability to control infectious diseases by reducing treatment effectiveness, prolonging illness duration, raising mortality rates, and increasing healthcare costs. This study aimed to identify the common rate of bacterial resistance against antibacterial agents in MNGHA, Jeddah, Saudi Arabia, and to assess the practice of appropriate antibiotic treatment.
In this study, the top 10 most common causative agents of UTIs  8%). Despite the lack of significant differences between isolated organisms across age groups, most of the causative organisms identified in this study were more prevalent (25.5%) in the group aged 76-85 years than in other age groups.
Among the most commonly prescribed antibiotics for UTI management, the most commonly identified uropathogen in the present study (E. coli) was most resistant to ampicillin (56.4%), followed by ceftriaxone (33.8%), ciprofloxacin (3.8%), amoxicillin (2.6%), and sulfamethoxazole/trimethoprim (1.7%). A similar result was reported in a study of three governmental hospitals (Najran General Hospital, Khalid Hospital, and Najran University Hospital) in the Najran region of Saudi Arabia, which aimed to investigate the antimicrobial resistance patterns of 136 outpatient urine samples. In this prior study, E. coli (58.5%) was the most common causative agent of UTIs, with an ampicillin resistance rate of 56.94% [23]. Although the emergence of antibiotic resistance may vary regionally and geographically, the present results regarding UTIs appear to be consistent with global antibiotic resistance data. In a multinational, multicenter study of 19,756 urine samples collected from 2003 to 2010, E. coli showed aminopenicillin antibiotic resistance rates of 42% in Northern Europe, 59% in Southern Europe, 60% in Asia, and 53% in South America and Africa [24].
Among the isolates from respiratory sources, the most common bacterial pathogen was P. aeruginosa, totaling 162 isolates (28.5%). Of these P. aeruginosa isolates, most (51.9%) were resistant to piperacillin/tazobactam, followed by ciprofloxacin (25%), ampicillin (10.6%), ampicillin/sulbactam (3.8%), and meropenem (2.9%). Similarly, in a study of 10 medical centers from all regions of Canada, the P. aeruginosa isolate was the predominant respiratory organism (26.2%; 423/1,612 isolates) [25]. These findings are also consistent with those of a more recent study in which more than 20% of P. aeruginosa isolates were resistant to piperacillin/tazobactam [26]. In the present study, K. pneumoniae was the secondmost prevalent bacteria (17.6%) in the isolates from respiratory sources. Regarding the 100 K. pneumoniae isolates, ampicillin resistance was highest (82.7%), followed by ceftriaxone (9.2%) and piperacillin/tazobactam (7.1%) resistance. This is contrary to the study by Al-Zalabani et al., in which the overall resistance found in 11,507 K.pneumoniae isolates was 61.7%, with remarkably high resistance rates of 80.4% and 58.7% to piperacillin and piperacillin/tazobactam, respectively [34]. There have been varied reports on the prevalence of Klebsiella species in different parts of the world [25].
The present study revealed high resistance rates for commonly used antibiotics, including ampicillin, amoxicillin/clavulanic acid, and sulfamethoxazole/trimethoprim. It has been suggested that the high rate of resistance to first-line therapies is due to several factors, including antibiotic misuse or self-medication and the ongoing unlawful dispensing of antibiotics in community pharmacies [27], despite the regulations and efforts applied by the Saudi Ministry of Health to alleviate emerging antibiotic resistance. The prescription of antibiotics in dentistry is of particular concern, as it has been reported that general dental practitioners are lacking knowledge regarding prescription of antibiotics in endodontic treatment and situations requiring prophylactic antibiotics [28]. Further investigation is needed to assess these concerns.
Importantly, an initiative strategy by the CDC known as the Antimicrobial Stewardship Programs (ASPs), which was developed as a preventive measure for increased resistance, outlined a set of seven integrated elements to be used by medical care providers globally: leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education [35]. Thus, the Saudi Ministry of Health has put efforts into implementing the ASPs in healthcare facilities [36].

Limitations
The population in our study is limited to one particular tertiary healthcare center in Jeddah, Saudi Arabia and this may not represent the antimicrobial resistance trends in another region within the same country. Additionally, the present study was based on information from patients' files. The BESTCare patient data documentation system, which enabled physicians to monitor each patient's course of antibiotics and guide them through proper and reliable antibiotic management, helped the researchers track patient records. However, incomplete documentation of certain prescribed antibiotics and their impacts on patient outcomes was considered a limitation. Also, communication with infectious disease specialists could have helped in understanding the hospital's protocol regarding antibiotic resistance.

Conclusions
In this study, high levels of antibiotic resistance were observed in both Gram-negative and Gram-positive bacteria. For better implementation of antibacterial stewardship and the optimization of empirical therapies, updated epidemiological data from a given community is necessary to determine the actual pattern of bacterial resistance within that community. Moreover, future studies should assess the impact of maternal antibiotic administration on newborns and the spread of ABR bacteria.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Institutional Review Board of King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia issued approval SP20/050/J dated April 22, 2020. The study was conducted in accordance with the Declaration of Helsinki. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.